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African American Couple

New Client Forms

New Client Forms

For your convenience, our intake forms are available to print from the website. Choose the intake packet that is listed for your counselor and that is for the appropriate age bracket. For example, if you are seeing Jennifer and if the client is a child, print all forms from that section. Carefully read and complete the intake forms IN BLACK INK and bring them with you to your first appointment. Please bring all pages of the forms (not just the signature pages); we will be happy to give you copies of them if you wish. This will save a lot of time so we can make the best use of your first appointment!

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*For couples counseling, each partner needs to complete his or her own intake packet.


Jennifer's Intake Packet for Adults (Age 18 and older)

Patient Health Questionnaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent

Acknowledgement of Financial Responsibility

Jennifer's Intake Packet for Children (Ages 6 through 17)

Patient Health Questionnaire - ages 12 and up only
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility


Jennifer's Intake Packet for Couples* Counseling

Patient Health Questionnaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Gottman Permission Form
Acknowledgment of Financial Responsibility


Sarah's Intake Packet for Adults and Couples* (Age 18 and older)

Patient Health Questionnaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility


Sarah's Intake Packet for Teens (Ages 15 through 17)

Patient Health Questionnaire 
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility

 

Emily’s Intake Packet for Adults and Couples* (Age 18 and older):

Patient Health Questionnaire
Personal Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility

Emily’s Intake Packet for Children (Ages 8 through 17):

Patient Health Questionnaire – ages 12 and up only
Personal Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility

 

J'Nae's Intake Packet for Children and Adolescents (Ages 3 through 17)

Patient Health Questionnaire 
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility

 

Robyn's Intake Packet for Adults  (Age 18 and older)

Patient Health Questionnaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility

 

Robyn's Intake Packet for Children and Adolescents (Ages 6 through 17)

Patient Health Questionnaire 
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility

 

Antoine's Intake Packet for Adults  (Age 18 and older)

Patient Health Questionnaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility

 

Lauren's Intake Packet for Adults and Couples* (Age 18 and older)

Patient Health Questionnaire
Professional Disclosure Statement
Consent for Audio Recording
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility

 

Katie's Intake Packet for Adults and Couples* (Age 18 and older)

Patient Health Questionnaire
Professional Disclosure Statement
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility


Katie's Intake Packet for Teens (Ages 15 through 17)

Patient Health Questionnaire - Ages 12 and up only
Professional Disclosure Statement
Child Development History
Authorization to Release Information
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Acknowledgement of Financial Responsibility

 

Parent Counseling Group Intake Packet (One Per family)

Group Registration Form
Personal Disclosure Statement
Notice of Privacy Practices
Credit Card Payment Form
PHI Consent
Confidentiality Statement

 

6614 Shallowford Road Suite 250
Lewisville NC 27023